Principles of Disease Management: Physician View (paper-based) in office documentation- patient risk questionnaire,H&P form/guide (focused materials increase efficientcy) eg: Reminders to MDs- for elements of history, physical exam, lab,treatment plan elements guidelines- drugs, referrals, recognition/care of co-morbidities Monitor and compare performance to peers

Sx’s hyper-,hypoglycemia Glucose monitoring Diet, exercise, ETOH, smoking Depression sx’s

eg: Triage center integrated multiple disease management programs, at a cost

Principles of Disease Management: Triage/Stratify Risk Triage center: based on DM Disease Management Program Referral Guidelines- based on call from MD for urgent referrals - center’s review of data after MD selects 'enroll' on encounter sheet a.nml risk- 'routine education',classes b. adverse factors- specific care- eg:bp, lipids, cardiac etc c. High risk- HIGH RISK Program- one-on one, follow up calls

Principles of Disease Management: Patient Interaction with System MD, Case manager, Nutritionist, Nurse Educator, other Health care providers Person-person, telephone, fax

Principles of Disease Management: Establish Outcomes to Follow Process outcomes Clinical result outcomes- eg: HgA1c, BP, Microalbumin, Lipids Establish goals of program - ie- how many patients achieve process / outcome goals Create monitoring/reporting mechanism

Percent of Patients at Target BP Goal (<135/<85), initial cohort (n=121)

Mean LDL Concentrations (Target<100mg/dl), initial cohort (n=121)